ACR Manual on Contrast Media:

https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf 

What do I do!?

Pre-Medication Recommendations and Guidelines

Specific Recommended Premedication Regimens Elective Premedication (12- or 13-hour oral premedication) 

1. Prednisone-based: 50 mg prednisone by mouth at 13 hours, 7 hours, and 1 hour before contrast medium administration, plus 50 mg diphenhydramine intravenously, intramuscularly, or by mouth 1 hour before contrast medium administration. 

2.  Methylprednisolone-based: 32 mg methylprednisolone by mouth 12 hours and 2 hours before contrast medium administration. 50 mg diphenhydramine may be added as in option 1. 

Although never formally compared, both regimens are considered similarly effective. 

(The presence of diphenhydramine in regimen 1 and not in regimen 2 is historical and not evidence-based. Therefore, diphenhydramine may be considered optional).

PATIENT SELECTION AND PREPARATION STRATEGIES BEFORE CONTRAST MEDIUM ADMINISTRATION 

If a patient is unable to take oral medication:

1. Option 1 may be used substituting 200 mg hydrocortisone IV for each dose of oral prednisone. If a patient is allergic to diphenhydramine in a situation where diphenhydramine would otherwise be considered, an alternate anti-histamine without cross-reactivity may be considered, or the anti-histamine portion of the regimen may be dropped. 

Accelerated IV Premedication (in decreasing order of desirability) 

1. Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV immediately, and then every 4 hours until contrast medium administration, plus diphenhydramine 50 mg IV 1 hour before contrast medium administration. This regimen usually is 4-5 hours in duration. 

2. Dexamethasone sodium sulfate (e.g., Decadron®) 7.5 mg IV immediately, and then every 4 hours until contrast medium administration, plus diphenhydramine 50 mg IV 1 hour before contrast medium administration. This regimen may be useful in patients with an allergy to methylprednisolone and is also usually 4-5 hours in duration. 

3. Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV, plus diphenhydramine 50 mg IV, each 1 hour before contrast medium administration. 

This regimen, and all other regimens with a duration less than 4-5 hours, has no evidence of efficacy. It may be considered in emergent situations when there are no alternatives.